The Hip from “Cradle to Grave”

1. The Hip from “Cradle to Grave” Haemish Crawford Ascot Hospital Starship Children’s Hospital

2. Developmental dysplasia hip DDH • Irritable vs. septic hip • Perthes disease • Slipped Upper Femoral Epiphysis (SUFE) • Hip arthroscopy • Total hip joint replacement • Revision hip replacement

3. DDH - The Problem • Incidence of late DDH is increasing • “Hips are not checked” • “Early discharge” • “Inexperienced examiners” • “No screening protocols” • “High risk babies not referred on”

4. DDH • Risk factors • Breech presentation • Family history • Diagnosis • Clinical examination • Ultrasound • Antenatal • Postnatal • X-ray (AP pelvis) • At 4 months

5. Clinical Examination Ortolani Test Barlow test

6. Skin Creases

7. Decreased Abduction

8. Ultrasound Scan

9. AP pelvis X-ray 4 to 5 months

10. Treatment: Pavlik Harness

11. Walking child Limping Leg length discrepancy

12. Irritable vs. Septic Hip

13. Irritable Hip Septic Hip Age 6 5.5 Male: Female 3.2 : 1.2 1.3 : 1.1 Ethnicity

14. Irritable Hip Septic Hip Preceding injury 16% 12% Preceding illness 29% - Duration of preceding Sxs 3.2 days 2.4 days Fever 4% 64% Malaise 16% 64% Weight bearing 55% 0

15. Irritable Hip Septic Hip • Ave Temp 36.6 38.3 ( 35.6-39.7) ( 36-39.5) • WCC 9.6 13.2 (4.6-15.8) (4.1-23.9) • Diff 5.3 10.3 (2.6-10.7) (3.9-18.4) • ESR 8 50 • CRP 4.2 93.5 • BC 0 7

16. Septic Hip: Sensitivities • Presenting features 1.History of fever/malaise 77% 2.Fever >38 degrees on admission 77% 1 and 2 86% • 3.WCC > 12 or diff > 10 72% 1 or 2 and 3 100%

17. Conclusions • Septic hip is rare • Male predominance and similar age range to irritable hip but increased frequency in Maori and Pacific Islanders • Initial presentation parameters are sensitive

18. Continue to recommend admission in • Those with clear history of current illness • Maori or Pacific Islander • Elevated temperature • Any elevation of WCC esp. PMNL • Raised ESR or CRP • Inability to weightbear should be considered • ? Children < 4 years

19. Perthes Disease • Avascular necrosis of femoral head • Aetiology still unclear • Treatment extremely controversial • Activity modification, pain relief and maintain movement • Refer to specialist • 4 monthly x-ray • Prognosis particularly good if < 5 years old at time of diagnosis

20. Slipped Upper Femoral Epiphysis (SUFE) • Cause still unclear • Maori and Polynesian adolescents > 10 yrs old • Usually obese • Girls > boys • Pain in hip +/- thigh +/- knee • Think bilateral • X-ray both hips AP pelvis AND lateral

23. Hip Arthroscopy

24. Hip Pain Where do you start? • Extraarticular • Intraarticular • Both • Neither – referred!

25. Intraarticular Causes of Hip Pain • Bone • Femoral neck stress fracture • SUFE • Perthes disease • Avascular necrosis femoral head • Articular cartilage • Osteochondritis dissecans • Osteoarthritis • Chondral lesions • Labrum • Tear • Synovium • Synovitis (e.g. inflammatory) • Synovial chondromatosis (loose bodies) • PVNS (pigmented villonodular synovitis) • Septic arthritis • Ligaments • Ligamentum teres rupture

26. The Labrum

27. Attachment Shape

29. How do you make the diagnosis? • History • Mechanism of injury • “twisted running” vs. “hyperextension in rugby tackle” • Mechanical symptoms • Intermittent pain or catching, sharp or stabbing nature • Localising symptoms • “C – sign” : characteristic hip joint pathology • Posterior pain : rarely intraarticular cause • Sitting pain and pain on standing

30. Examination • “Impingement” test • Groin pain on flexion , internal rotation and adduction • Reproduce symptoms (clicking, pain …) • Compare to other side • Faber test (snapping iliopsoas)

32. Surgery

33. Functional outcome • Post-op • NAHS 51.20 to 83.32 • WOMAC 53.40 to 83.36 • 66% >80 NAHS • 78% >80 WOMAC

34. Hip Arthroscopy Summary • “Newish” technique • Minimally invasive for intra-articular problems • Delays need for total hip joint replacement • Functional outcomes very good / excellent

35. Total hip joint replacements • When? • Pain is the only reason to have one • “you” tell me when you want to have one • What type? • Huge number of options • Cemented, uncemented, hybrid! • Surfaces • Metal on polyethylene (Charnley) • Metal on metal • Ceramic on ceramic

36. Surface replacements • These are total hip joint replacements with same complications and some new ones • Metallosis

37. Rehabilitation • 4-5 nights in hospital • 3-4 weeks on crutches • Complications • Infection • Superficial or deep • Dislocation • DVT and /or PE • Or just swelling!

38. THJR Summary • Referral letter important • Does the patient “want a THJR” • Co-morbidities • Medications • Thromboembolic problems • Social situation • Myriad of options – new isn’t always better! • Complications • Contact surgeon to review • Antibiotics only if definitely superficial infection

39. Revision Hip Joint Replacement Complex Newer instrumentation and implants making it easier Not all the components need revising Can have multiple revisions Rehabilitation and hospital stay longer – 6 weeks crutches

41. Summary • The hip can be a difficult joint to sort out • Think • Intraarticular • Extraarticular • Referred (especially if buttock) • X-rays are mandatory especially in children • Knee pain mean hip pathology